Provider Demographics
NPI:1922678564
Name:WOOD, LESLY
Entity Type:Individual
Prefix:
First Name:LESLY
Middle Name:
Last Name:WOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 PARK ST
Mailing Address - Street 2:
Mailing Address - City:ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703-3143
Mailing Address - Country:US
Mailing Address - Phone:508-222-2021
Mailing Address - Fax:508-342-1907
Practice Address - Street 1:150 EMORY ST
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-2439
Practice Address - Country:US
Practice Address - Phone:508-222-2021
Practice Address - Fax:508-342-1907
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2303986363L00000X
MARN26303986363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110174364AMedicaid